The regular update of the German S3 guidelines on long-term opioid therapy for chronic noncancer pain (CNCP), the"LONTS" (AWMF registration number 145/003), began in November 2013.
The guidelines ...were developed by 26 scientific societies and two patient self-help organisations under the coordination of the Deutsche Schmerzgesellschaft (German Pain Society). A systematic literature search in the Cochrane Central Register of Controlled Trials (CENTRAL), Medline and Scopus databases (up until October 2013) was performed. Levels of evidence were assigned according to the classification system of the Oxford Centre for Evidence-Based Medicine. The strength of the recommendations was established by multistep formal procedures, in order to reach a consensus according to German Association of the Medical Scientific Societies ("Arbeitsgemeinschaft der Wissenschaftlich Medizinischen Fachgesellschaften", AWMF) regulations. The guidelines were reviewed by the Drug Commission of the German Medical Association, the Austrian Pain Society and the Swiss Association for the Study of Pain.
Opioids are one drug-based treatment option for short- (4-12 weeks), intermediate- (13-25 weeks) and long-term (≥ 26 weeks) therapy of chronic osteoarthritis, diabetic polyneuropathy, postherpetic neuralgia and low back pain. Contraindications are primary headaches, as well as functional somatic syndromes and mental disorders with the (cardinal) symptom pain. For all other clinical presentations, a short- and long-term therapy with opioid-containing analgesics should be evaluated on an individual basis. Long-term therapy with opioid-containing analgesics is associated with relevant risks (sexual disorders, increased mortality).
Responsible application of opioid-containing analgesics requires consideration of possible indications and contraindications, as well as regular assessment of efficacy and adverse effects. Neither an uncritical increase in opioid application, nor the global rejection of opioid-containing analgesics is justified in patients with CNCP.
In line with the increased life expectancy of people in Germany, the probability of falling ill with a malignant disease is continuously increasing. About 480,000 people in Germany contract cancer ...every year. One of the most important symptoms of a malignant disease is pain. Between 40 and 100% of patients with advanced cancer suffer from pain. The aim of this investigation is to show how German general practitioners care for these patients using analgetics.
The data were extracted from the CONTENT database (CONTinuous morbidity registration Epidemiologic NeTwork) of the Department of General Practice and Health Services Research at the University Hospital in Heidelberg. This database has data from more than 200,000 patients and more than 3 million physician/patient contacts. The prescriptions were classified using the ATC code.
Patients experiencing pain from cancer received all kinds of analgetic drugs. The data comprises 9752 prescriptions for 1362 patients. There were 4975 (51.1 %) prescriptions for Class 1 analgesics, 929 (9.5 %) for Class 2 analgetics and 1918 (19.7 %) prescriptions for Class 3 analgetics. Coanalgetics were prescribed 1930 (19.7 %) times. 1,167 patients (85.7 %) were treated in the correct manner according to the guidelines of the World Health Organisation and 195 (14.3 %) were not.
Most GPs in Germany follow the principles of WHO structured pain therapy. However, further improvement of the results may be achieved through intensive training of colleagues.
The care of patients at the end of life focuses on preservation of the quality of life, symptom control and fulfillment of the preferred place of death. Only few care and outcome-related data for ...primary palliative care in Germany are available; therefore, the objective was to examine the quality of life, symptom control and place of death of patients with palliative treatment by general practitioners (GP).
The study is part of the PAMINO project, a non-randomized, controlled trial evaluating the effectiveness of continuing medical education for GPs (≥ 40 h) in palliative care (ISRCTN78021852). Cancer patients with an estimated life expectancy of less than 6 months were recruited by GPs with (PG) or without (CG) continuing education and documented the diagnosis, medication based on the hospice and palliative care collation ( Hospiz- und Palliativ-Erfassung, HOPE) core documentation and the preferred place of death. Patients rated their symptom burden and health-related quality of life using the quality of life questionnaire (QLQ-C15-PAL). Baseline (t0) data at enrollment and the last individual (t1) assessment were used for the analysis.
Data of 68 patients (PG: n = 43, CG: n = 25, mean age 69.2 ± 12 years, average time since cancer diagnosis 14 months) were available at t0 and t1 (mean period 4.0 ± 2.1 months). Physical function decreased while emotional functioning remained stable. Patient-perceived pain did not increase; however, GPs intensified the pain therapy. The PGs prescribed non-opioid analgesics more frequently than CGs. During the observation period 59 patients died of which 40 out of 48 (83 %) as preferred at home.
Stable emotional functioning, good symptom control in cancer patients at the end of life and the high rate of dying at home as preferred suggest that GPs with specific training can ensure high-quality general palliative care.
Exercise therapy is an efficacious treatment for patients with peripheral arterial disease (PAD). The study aimed to determine the initiation and adherence of PAD patients with intermittent ...claudication in a supervised community-based walking exercise program.
Over a period of one year, PAD patients with Fontaine stage II attending an angiological outpatient setting were consecutively recruited to the study. Willingness, commencement and adherence of patients in the training program were recorded.
Of 462 patients with intermittent claudication, only 166 (36%) subjects fulfilled the requirements for participation in physical exercise training. Of these eligible patients, 110 (66%) persons accepted the invitation to attend exercise therapy. However, despite the commitment, 58 (35%) subjects failed to initiate attendance in the training program. Fifty-two (24%) patients did start the program but 16 (8%) patients did not complete more than three initial training sessions. Over a three-month period, regular attendance was registered for 36 (16%) patients.
Although physical exercise improves symptoms and mobility of patients with intermittent claudication, only about one-third of them is commencing an exercise program. Through lacking initiation and discontinuation, only a small percentage of claudicants permanently engages in a walking exercise program.
The aim was to explore the expectations of general practitioners (GPs) towards specialized outpatient palliative care (SAPV) focused on older patients in the last phase of life.
A standardized postal ...survey was carried out with 1,962 GPs in Lower Saxony with an analysis of physician and practice-related factors.
The response rate was 46% (n=897) and SAPV was known to 68% of the participants (n=599) of whom 48% (n=288) assumed that SAPV will improve the healthcare for older patients in the last phase of life. The GPs favored advice by and collaborative patient care with SAPV teams. Younger and female GPs, and GPs who had been practicing for a shorter period or working in a group practice showed greater interest in collaboration than other colleagues.
The perception of patients in specialized palliative care with its current focus on cancer patients is different from the perception in general practice with its focus on geriatric and multimorbid patients. This may be a reason for the skepticism showed in this study whether SAPV will actually improve healthcare in the community. However, with respect to the concept and framework SAPV has the potential to fulfill GPs expectations and should be focused on counseling and collaborative services. The knowledge about physician and practice-related factors shaping GPs attitudes towards SAPV can be helpful to further implement SAPV into practice.
Eligibility of patients with peripheral arterial disease (PAD) for exercise therapy is the most important requirement for predicting their training group adherence.
In this prospective, exploratory ...study over a period of 1 year, a total of 462 PAD patients of an angiological outpatient routine care setting were consecutively recruited to the study. As non-eligibility criteria for exercise therapy were defined: resting pain or gangrene (Fontaine stage III and IV PAD), the inability to complete treadmill exercise, or premature treadmill discontinuation due to non-vascular walking pain. Also, PAD patients without subjective walking limitation (Fontaine stage I PAD) were assessed as unwilling, i.e. non-eligible for exercise training adherence. Criterion for patients eligibility was the occurrence of intermittent claudication on treadmill test (Fontaine stage II PAD).
A total of 346 patients (age median 71 years, males 58.5%) were candidates for conservative therapy. Of them, 166 subjects (48%) were assessed as eligible for participation in walking exercise program. 180 of the patients (52%) were deemed as non-eligible to perform walking exercise therapy. 115 patients (33%) were physically limited by critical limb ischemia (Fontaine stage III and IV PAD), severe comorbid cardiovascular disease or orthopaedic disorder. In 65 PAD patients (19%) the subjective walking capacity was not restricted. Social, logistical or other factors were found in 27 patients (8%) to be barriers for exercise training commencement.
In half of the PAD patients whose attendance in a community-based walking exercise program would be a therapeutically reasonable activity, a range of vascular and non-vascular factors are obstacles for participation. Further research is needed to investigate what measures might enhance the proportion of exercise therapy participants.
Family practitioners (FPs) who work in Out-Of-Hours Care (OOHC) - especially in rural areas - complain about high workload related to low urgency and potentially unnecessary patient presentations ...with minor ailments. The aim of this study was to describe Reasons for Encounter (RFEs) in primary OOHC taken into account the doctor's perspective in the context of high workload without knowing patients' motives for visiting an OOHC-centre.
Within this descriptive study, OOHC data from 2012 were evaluated from a German statutory health insurance company in the federal state of Baden-Wuerttemberg. 1.53 Million of the 10.5 Million inhabitants of Baden-Wuerttemberg were covered. The frequency of the ICD-10 diagnoses was determined at the three- and four-digit-level. The rate of hospitalizations was used to estimate the severity of the evaluated cases.
Taken as a whole, 163,711 reasons for encounter with 1,174 ICD-10 single diagnoses were documented, of these 62.2% were on weekends. Less than 5.0% of the examined patients were hospitalized. Low back pain-dorsalgia (M54) was the most common diagnosis in OOHC, with 10,843 cases. Injuries were found twelve times in the list of the 30 most frequent diagnoses. The most frequent infectious disease was acute upper respiratory infection of multiple and unspecified sites (J06). By analysing the ICD codes to four-digits and looking at the rate of hospitalizations, it can be assumed that many RFEs were of less urgency in terms of the prompt need for medical treatment.
While it is acknowledged that it can be difficult to make an exact diagnosis in an OOHC setting, after analysing the ICD-10 diagnoses, the majority of reasons for encounter in OOHC were determined to be of low urgency, meaning that patients could have waited until regular consultation hours. In the OOHC setting, it is important to understand RFEs from both the patient perspective and the family practitioner perspective. Additionally, results like these can be used in staff education especially improving triage methods and medical recommendations and in developing specific guidelines for OOHC in Germany. Analysis of routine data, such as in this study, contributes to this understanding and contributes to resolving problems of coding.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Hintergrund:
Entscheidungen am Lebensende sind häufig wegen der existentiellen Bedrohung schwierig und im Dialog zwischen Arzt und Patient nicht immer einfach zu beantworten. In vielen Kliniken sind ...daher auf Initiative von Palliativmedizinern ethische Fallkonferenzen implementiert worden. Auch in Pflegeheimen werden zunehmend ähnliche Strukturen etabliert.
Methodik:
Mittels Literaturrecherche und Umfrage in den Allgemeinmedizinischen Universitätsabteilungen in Deutschland wird der Stand ethischer Fallkonferenzen im allgemeinmedizinischen Versorgungsbereich untersucht
Ergebnisse:
Die Ergebnisse der Umfrage und Recherche werden auf dem Kongress präsentiert. Zum jetzigen Zeitpunkt können nur wenige Ansätze ethischer Fallkonferenzen überschaut werden. Endgültige Ergebnisse liegen aber noch nicht vor.
Diskussion:
Nach jetzigem Kenntnisstand ist das Verfahren der ethischen Fallkonferenz im hausärztlichen Versorgungsbereich sehr wenig etabliert. Die Barrieren und die Möglichkeiten der Entwicklung werden dargestellt. Besonders wichtig erscheint dabei eine kontinuierliche Entwicklungen im Bereich der Altenpflegeheime.
After publication of the original article 1, it came to the authors’ attention that Figs. 2, 3 and 4 were presented incorrectly. Upon investigation, a change requested by the author at proofing had ...been misinterpreted, resulting in the Figures and their captions being out of sequence. Fig. 2 Distribution of the diagnoses “Injury of unspecified body region” (T14) at the four-digit level Fig. 3 Distribution of the diagnoses “Essential (primary) hypertension” (I10) at the four-digit level Fig. 4 Distribution of the diagnoses “Abdominal and Pelvic Pain” (R10) at the four-digit level The original article has now been updated in order to rectify the error, and the Figures are published in their correct form in this erratum.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Zusammenfassung
Hintergrund
Die planmäßige Aktualisierung der S3-Leitlinie zur Langzeitanwendung von Opioiden bei chronischen nicht-tumorbedingten Schmerzen (LONTS), AWMF-Registernummer 145-003, ...wurde ab November 2013 vorgenommen.
Methodik
Die Leitlinie wurde unter Koordination der Deutschen Schmerzgesellschaft von 26 wissenschaftlichen Fachgesellschaften und zwei Patientenselbsthilfeorganisationen entwickelt. Die Literaturrecherche erfolgte über die Datenbanken CENTRAL, Medline und Scopus (bis Oktober 2013). Die Graduierung der Evidenzstärke erfolgte nach dem Schema des Oxford Center of Evidence-Based Medicine. Die Formulierung und Graduierung der Empfehlungen erfolgte in einem mehrstufigen, formalisierten Konsensusverfahren nach dem Regelwerk der Arbeitsgemeinschaft der Wissenschaftlich Medizinischen Fachgesellschaften (AWMF). Die Leitlinie wurde von der Arzneimittelkommission der Deutschen Ärzteschaft, der Österreichischen Schmerzgesellschaft und der Schweizer Gesellschaft zum Studium des Schmerzes begutachtet.
Ergebnisse
Opioidhaltige Analgetika sind eine medikamentöse Therapieoption in der kurz- (4–12 Wochen), mittel- (13–25 Wochen) und langfristigen Therapie (≥ 26 Wochen) von chronischen Arthrose- und Rückenschmerzen sowie chronischen Schmerzen bei diabetischer Polyneuropathie und Postzosterneuralgie. Kontraindikationen sind primäre Kopfschmerzen sowie funktionelle und psychische Störungen mit dem (Leit-)Symptom Schmerz. Bei allen anderen Krankheitsbildern ist eine kurz- und langfristige Therapie mit opioidhaltigen Analgetika als individueller Therapieversuch zu bewerten. Eine Langzeittherapie mit opioidhaltigen Analgetika ist mit relevanten Risiken (sexuelle Störungen, erhöhte Mortalität) verbunden.
Schlussfolgerung
Ein verantwortungsvoller Einsatz von opioidhaltigen Analgetika verlangt die Berücksichtigung möglicher Indikationen und Kontraindikationen sowie eine regelmäßige Erfassung von Wirksamkeit und Nebenwirkungen. Eine unkritische Ausweitung als auch pauschale Ablehnung einer Therapie mit opioidhaltigen Analgetika von Patienten mit chronischen nicht-tumorbedingten Schmerzen ist nicht gerechtfertigt.
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